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Please select one of the following two options by signing and returning the form via FAX or postal mail to KB Visions, Inc. 6787 Riverside Dr. Atlanta, GA 30328.

Our pharmacy is interested in reviewing a license agreement to make, distribute, and/or sell ophthalmic cyclosporine. We understand if we choose to license, there will be a one time licensing fee of $300.00. In addition, monthly royalty payments of either 25% of net sales of ophthalmic cyclosporine or $6.00 per unit, whichever is greater, will be due along with your report by the 15th of each month.

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Our pharmacy will not compound ophthalmic cyclosporine in the future, and will refer all requests for ophthalmic cyclosporine to KB Visions, Inc.

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